I. Problem/Condition.

Left lower quadrant pain is a descriptive term indicating pain in the lower abdomen and left iliac fossa. There a number of disctinct disorders that can cause left lower quadrant pain and most are related to the underlying structures present in that region of the abdomen.

II. Diagnostic Approach.

A. What is the differential diagnosis for this problem?

In evaluating a patient with pain in the left lower quadrant, it is helpful to think systematically about the underlying structures in that area. Of course, the gender of the patient is critical in this regard and should not be ignored. In both men and women, left lower quadrant pain can be due to disease involving the large intestine, inguinal canal, kidney, ureter and abdominal wall.

In men, testicular torsion can sometimes present as left lower quadrant abdominal pain. In women, conditions involving the ovary, fallopian tubes, and uterus can all cause pain in the left lower quadrant. These include, ovarian cancer and torsion, ectopic pregnancy, salpingitis, tuboovarian abscess, uterine fibroids, pelvic inflammatory disease, and endometritis. Finally, other conditions that generally affect the entire abdomen may, at times, be located to the left lower quadrant and cause pain. These include mesenteric ischemia, peritonitis, bowel obstruction, sickle cell crises and narcotic withdrawal.

B. Describe a diagnostic approach/method to the patient with this problem.

In patients presenting with left lower quadrant abdominal pain, a detailed patient history, thorough examination and select diagnostic testing are essential in making the correct diagnosis.

1. Historical information important in the diagnosis of this problem.

First, ask the patient to localize their abdominal pain and also describe the nature of the pain. Is it sharp or dull? Is it associated with position or eating? Does the pain radiate? If so, to where? Renal colic is classically a "loin to groin" radiating type of pain whereas ischemic colitis may be temporally related to eating food. Has the patient had a change in bowel habit? Is there a change in the stool caliber and is there any reported weight loss, abdominal swelling, anorexia or blood in the stool? Colorectal cancer may present with weight loss, tenesmus, blood in the stool and thin "string bean" shaped stools. And distension may indicate an obstructed intestine.

A history of predominant diarrhea or constipation or both, associated with abdominal pain for at least 3 days a month for the last 3 months and improvement with defecation and or change in the frequency or nature of stools may indicate irritable bowel syndrome. Is the patient pregnant or could she be pregnant? Left lower quadrant pain with associated vaginal bleeding, and menstrual cycle abnormalities may indicate ectopic pregnancy. Does the patient have any fevers or chills? Endometritis classcially presents with uterine pain, vaginal bleeding and fever.

Does the patient have a history of diverticulosis? If so, left lower quadrant pain may be due to diverticulitis and micro-perforation of a diverticulum. In women, bilateral lower abdominal pain (pelvic pain) associated with coitus, fever or abnormal uterine bleeding may be due to pelvic inflammatory disease. Finally acute onset, severe pain associated with minimal movement by the patient or a history of worsening pain with movement, may indicate a ruptured viscous and peritonitis.

2. Physical Examination maneuvers that are likely to be useful in diagnosing the cause of this problem.

In addition to performing a thorough physical examination, confirm the patients vital signs, including blood pressure, heart rate and temperature in order to rule out a life threatening illness like sepsis that may be associated with the patients left lower quadrant abdominal pain.

Perform a rectal examination and test the stool for occult blood if gross hematochezia is not present. Note the presence or absence of an obstructing mass in the rectal vault. In men, perform a proper testicular examination in order to rule out torsion or orchitis as a possible diagnosis. In women, a pelvic examination is essential to elicit Chandelier's sign and adnexal tenderness or mass indicating possible cervicitis, PID, salpingitis, tuboovarian abscess, fibroid, ovarian mass or ectopic pregnancy as a possible cause for the patient's left lower quadrant pain.

3. Laboratory, radiographic and other tests that are likely to be useful in diagnosing the cause of this problem.

In the evaluation of a patient with left lower quadrant abdominal pain, it is helpful to obtain a complete blood count. An elevated WBC count may indicate underlying infection, and the presence of anemia may correlate with gastrointestinal, gynecologic or genitourinary sources for blood loss.

A urinalysis may reveal the presence of gross blood or microscopic hematuria indicating a ureteric stone or other renal or ureteric pathology as the source for the patient's pain.

A basic metabolic panel is helpful in order to evaluate the patients renal function, and a deranged BUN or serum creatinine may indicate an obstructive uropathy.

A hemeoccult test should be performed to rule out the presence of blood in the stool.

A pregnancy test should be obtained in all women of child-bearing age. Microscopy of any abnormal vaginal discharge and tests for chlamydia and gonococcus should be obtained in any women with suspected STI or PID.

Plain film x-rays of the abdomen (supine and standing) can be useful in ruling out viscous perforation and intestinal obstruction by looking for free air under the diaphragm and dilated bowel loops, respectively. Where computed tomography (CT) scanning is readily available, plain film x-rays of the abdomen may be omitted. CT of the abdomen can provide a wealth of information for diagnosing the cause of left lower quadrant abdominal pain including evaluation of the bowel, the left kidney and ureter, the uterus, fallopian tube and ovary and the abdominal wall.

Pelvic and testicular ultrasounds can also add very useful diagnostic information when ruling out ovarian, fallopian or testicular causes for left lower quadrant abdominal pain. Also an ectopic pregnancy may be visualized.

C. Criteria for Diagnosing Each Diagnosis in the Method Above.

See previous section.

D. Over-utilized or “wasted” diagnostic tests associated with the evaluation of this problem.

None

III. Management while the Diagnostic Process is Proceeding.

A. Management of Clinical Problem Left-Lower Quadrant Abdominal Pain.

Emergent management of the patient with left lower quadrant pain focuses mainly on pathologies associated with peritonitis like instestinal obstruction and perforation. In other words, management of the acute "surgical abdomen".

Acute, severe or unrelenting abdominal pain with associated fever, hypotension and dehydration, and peritoneal findings on examination including rebound, guarding and abdominal wall rigidity, should alert the examiner to the possibility of a surgical abdomen. This may result from a bowel perforation like in diverticulitis, acute mesenteric ischemia, ectopic pregnancy or ovarian torsion. However, this condition can also evolve over a period of weeks, as in the case of a partial bowel obstruction gradually progressing to a complete intestinal obstruction.

The elderly and patient with diabetes, renal failure and immunosuppression are at increased risk of developing a surgical abdomen and it is important to note that their symptoms may be more atypical or muted. In managing these patients with a surgical abdomen, obtain adequate intravenous access, initiate fluid resuscitation and obtain an urgent surgical consultation. Obtain stat laboratory studies as mentioned above, including a serum lactate. Perform a bedside ultrasound if possible to rule out vicous perforation, testicular or ovarian torsion, or ectopic pregnancy. If the patient is stable, obtain an abdominal CT scan to rule out the presence of free air or intestinal obstruction with dilated bowel loops.

B. Common Pitfalls and Side-Effects of Management of this Clinical Problem.

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